North Carolina Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) order template is created in accordance with the relevant state laws of North Carolina. This document allows individuals to express their wishes regarding resuscitation in the event of a medical emergency.
Please fill out the following information accurately:
- Name of Patient: ________________________
- Date of Birth: ________________________
- Address: ________________________
- City: ________________________
- State: North Carolina
- Zip Code: ________________________
- Phone Number: ________________________
Patient Declaration:
I, the undersigned, declare that I do not wish to receive cardiopulmonary resuscitation (CPR) or any other life-prolonging measures in the event of cardiac or respiratory arrest, as outlined in North Carolina General Statutes.
Signature: ________________________
Date: ________________________
Next of Kin or Health Care Proxy:
- Name: ________________________
- Relationship: ________________________
- Phone Number: ________________________
Health Care Provider Information:
- Name: ________________________
- Address: ________________________
- Phone Number: ________________________
This DNR order should be prominently displayed in the patient's medical file and, preferably, on the patient's person for emergency responders.
Remember that it is important to discuss this decision with your health care provider and family members to ensure that everyone understands your wishes.